Replantation of digits: a review of predictive factors for survival

Amputated Digit Replantations: Critical Digit Ischemia Timing, Temperature, and Other Predictors of Survival

INTRODUCTION

A common consideration for replantation success is the ischemia time following injury and the preservation temperature. A classic principle within the hand surgery community describes 12 hours of warm ischemia and 24 hours of cold ischemia as the upper limits for digit replantation; however, these limits are largely anecdotal and based on older studies. We aimed to compare survival data from the large body of literature to aid surgeons and all those involved in the replantation process in hopes of optimizing success rates.

METHODS

The PubMed database was queried on April 4th, 2023, for articles that included data on digit replantation survival in terms of temperature of preservation and ischemia time. All primary outcomes were analyzed with the Mantel-Haenszel method within a random effects model. Secondary outcomes were pooled and analyzed using the chi-square statistic. Statistical analysis and forest plot generation were completed with RevMan 5.4 software with odds ratios calculated within a 95% confidence interval.

RESULTS

Our meta-analysis identified that digits preserved in cold ischemia for over 12 hours had significantly higher odds of replantation success than the amputated digits replanted with 0-12 hours of warm ischemia time ( P ≤ 0.05). The odds of survival in the early (0-6 hours) replantation group were around 40% greater than the later (6-12 hours) replantation group ( P ≤ 0.05). Secondary outcomes that were associated with higher survival rates included a clean-cut amputation, increased venous and arterial anastomosis, a repair that did not require a vein graft, and replants performed in nonsmokers ( P ≤ 0.05).

DISCUSSION

Overall, these findings suggest that when predicting digit replantation success, time is of the essence when the digit has yet to be preserved in a cold environment. This benefit, however, is almost completely diminished when the amputated digit is appropriately maintained in a cold environment soon after injury. In conclusion, our results suggest that there is potential for broadening the ischemia time limits for digit replant survival outlined in the literature, particularly for digits that have been stored correctly in cold ischemia.

Analyzing attempt and success factors for amputated digit replantation in Japan using the diagnosis procedure combination database

The number of amputated finger replantation has declined in the USA and Germany in recent years; however, there have been no reports on recent trends in Japan. We examined the current practices, attempts, and success factors of digit replantation in Japan. We hypothesized that the rates of digit replantation and success rates were consistently standardized in Japan. The diagnosis procedure combination database was used to analyze 14004 cases from April 2014 to March 2020, excluding multiple-digit amputations, thus focusing on 13484 patients. We evaluated replantation success rates and identified factors influencing replantation decisions using multiple logistic regression analysis. The key findings included a higher frequency of replantation in thumb cases and surgeries during overtime hours, on Sundays, and in educational institutions. Success rates were notably higher for thumb replantations and patients under 20 years of age. Patients over 65 years of age treated with urokinase showed higher failure rates, unrelated to regional or hospital case volumes. The number of amputated digit replantation surgeries in Japan was high during overtime hours, on Sundays, and in educational institutions. Region, hospital type, and hospital case volume were not associated with a low success rate across Japan.

Digital artery flow hemodynamics: An ultrasonographic study

BACKGROUND

There is a lack of data regarding the baseline hemodynamic blood flow parameters of the wrist and digits. Therefore, we aimed to quantify the digital and radial artery blood flow parameters using ultrasound and assess the influence of patient characteristics on hemodynamics.

METHODS

We analyzed ultrasonographic data from 25 patients (50 hands) between October 2019 and December 2021. Variables of interest included dimensions of the radial artery and index finger (IF) ulnar and radial digital arteries at the palmodigital crease and their corresponding flow parameters. We compared variables among men and women and patients with and without diabetes using Wilcoxon Rank Sum test.

RESULTS

Our cohort consisted of 18 women (36 hands) and three participants with diabetes (six hands). The mean diameter of the IF radial digital artery was 7 mm, and that of the ulnar digital artery was 10 mm. The average peak systolic velocity for the radial digital artery was 21.31 cm/sec, and for the ulnar digital artery, it was 30.03 cm/sec. Comparing men and women, the only significant difference found was in the time-averaged mean velocity for the ulnar digital artery (men:5.66 cm/sec vs. women:9.68 cm/sec, P = 0.02) and volume of flow for the ulnar digital artery (men:10.87cc/min vs. women:18.58cc/min, P = 0.03). We found no differences in blood flow parameters comparing participants with and without diabetes.

CONCLUSION

These data provide a baseline measurement of digital flow hemodynamics that can be used in future studies to model vascular flow after replantation.

Overview and management of complications after digital replantations

The main complications after digital replantation are discussed in this review article. These complications include vascular compromise, infection, partial necrosis, delayed union or nonunion, atrophy and so on. The countermeasures for these complications are reviewed and the authors' methods are also introduced and discussed.

Review of Replantation Services from a Level One Trauma Center in India

The aim of this article is to examine the elements that contribute to effective operation of a specialized replantation center and to provide readers with a general idea of the outcome of replantation services in India. A dedicated high-volume center coupled with a sound referral system is the backbone of replantation services in a country. A retrospective study was done on all patients who visited a level 1 trauma center in India from November 1, 2017, to December 31, 2018, for various amputations. The medical records and digital pictures of these patients were extracted from the records and analyzed. During the study period, 77 replants were performed on 63 patients at our center. Males were 68% of the study, mostly belonging to the 20 to 40 years age group (63%). Thirty-four percent of cases were smokers. Agricultural injuries (49%) were the most common cause of amputation. Finger replantation was the most common type of replantation (82%). The rate of successful replantation was highest for scalp (100%) followed by hand (71%) and thumb (67%). Setting up dedicated replantation services is essential, especially in highly populated areas. Manpower, resources, and a protocol-led approach help in achieving optimum results. A multidisciplinary team approach with round-the-clock availability plays a vital role in intraoperative decision-making and planning postoperative rehabilitation.

The effect of dobutamine treatment on salvage of digital replantation and revascularization

PURPOSE

One of the most common causes of a failure after replantation and revascularization surgeries is 'no reflow' from proximal artery that occurs, especially following crush and avulsion injuries. In this study, we aimed to evaluate the effect of dobutamine treatment on salvage of replanted and revascularized digits.

METHODS

The patients with no reflow phenomenon detected in the salvage operations of replanted/revascularized digits between the years 2017 and 2020 were included in the study. Dobutamine treatment was infused at a rate of 4 µg·kg-1·min-1 intraoperatively and of 2 µg·kg-1 min-1 postoperatively. Demographic data (age, sex), digit survival rate, ischemia time, and level of injury were retrospectively analysed. Pre-infusion, intraoperative and postoperative values of cardiac index (CI), mean arterial pressure (MAP), and heart rate (HR) were recorded.

RESULTS

The phenomenon of 'no reflow' was encountered in 35 digits of 22 patients who underwent salvage surgery due to vascular compromise. The survival rate in the revascularization group was 75%, while it was 42.1% in the replanted digits. Metaphysis level of proximal phalanx was the most common localization for 'no reflow' phenomenon. The least values of CI, MAP and HR to obtain sufficient perfusion in salvaged digits were as follows: 4.2 l.min-1.m-2, 76 mm Hg, and 83 beat·min-1, respectively.

CONCLUSIONS

It was demonstrated that dobutamine infusion at a rate of 4 µg·kg-1·min-1 intraoperatively and at 2 µg·kg-1·min-1 postoperatively has favorable effects on the vascular compromise derived from no reflow of proximal artery.

Effect of multiple-digit replantation in patients with amputated digits

PURPOSE

The replantation of multiple amputated digits is a technically challenging procedure for reconstructive surgeons that requires more time than the replantation of a single digit. We evaluated the effect of multiple-digit replantation on the success of digital replantation.

METHODS

Patients who experienced digital amputation and underwent digital replantation from January 2018 to December 2021 were studied retrospectively. Patients who experienced successful and failed replantation were compared, as were digits that survived or became necrotic after replantation. A multivariate logistic regression (MLR) analysis was performed to evaluate the independent factors of replanted digit survival.

RESULTS

There were 378 patients with 497 amputated digits who underwent digital replantation. Of all 378 patients, 298 underwent single-digit replantation, and the other 80 patients underwent multiple-digit replantation. A total of 83.3% of the replanted digits survived (414 of 497). Compared with patients with surviving replanted digits, significantly more patients with necrotic replanted digits underwent multiple-digit replantation (37.7% vs. 17.5%, p < 0.001). On the other hand, a digit that developed necrosis after replantation was more likely to have been involved in the replantation of three or more digits (16% vs. 29%, p = 0.005). The subsequent MLR analysis revealed that the likelihood of necrosis was 2.355 (p = 0.003) times higher in the replantation of three or more digits than in the replantation of one or two digits.

CONCLUSION

Patients who underwent multiple-digit replantation exhibited a higher incidence of necrosis in the replanted digits. In cases involving patients with multiple-digit amputation, it is crucial to prioritize and perform selective replantation based on the amputated digits.

Is Prolonged Use of Antibiotic Prophylaxis and Postoperative Antithrombotic and Antispasmodic Treatments Necessary After Digit Replantation or Revascularization?

BACKGROUND

Ensuring the patency of repaired vessels is pivotal in improving the success rate of digit replantation. There is no consensus on how to best approach postoperative treatment for digit replantation. The influence of postoperative treatment on the risk of failure of revascularization or replantation remains unclear.

QUESTIONS/PURPOSES

(1) Is there an increased risk of postoperative infection with early discontinuation of antibiotic prophylaxis? (2) How are anxiety and depression affected by a treatment protocol consisting of prolonged antibiotic prophylaxis and administration of antithrombotic and antispasmodic drugs and by the failure of a revascularization or replantation procedure? (3) Are there differences in the risk of revascularization or replantation failure based on the number of anastomosed arteries and veins? (4) What factors are associated with failure of revascularization or replantation?

METHODS

This retrospective study was conducted between July 1, 2018, and March 31, 2022. Initially, 1045 patients were identified. One hundred two patients chose revision of amputation. In all, 556 were excluded because of contraindications. We included all patients in whom the anatomic structures of the amputated part of the digit were well preserved, and those with an ischemia time for the amputated part that did not exceed 6 hours. Patients in good health without any other serious associated injuries or systemic diseases and those without a history of smoking were eligible for inclusion. The patients underwent procedures that were performed or supervised by one of four study surgeons. Patients were treated with antibiotic prophylaxis (1 week); patients treated with antithrombotic and antispasmodic drugs were categorized into the prolonged antibiotic prophylaxis group. The remaining patients treated with antibiotic prophylaxis for less than 48 hours and no antithrombotic and no antispasmodic drugs were categorized into the nonprolonged antibiotic prophylaxis group. Postoperative follow-up was for a minimum of 1 month. Based on the inclusion criteria, 387 participants with 465 digits were selected for an analysis of postoperative infection. Twenty-five participants with a postoperative infection (six digits) and other complications (19 digits) were excluded from the next stage of the study, in which we assessed factors associated with the risk of failure of revascularization or replantation. A total of 362 participants with 440 digits were examined, including the postoperative survival rate, variation in Hospital Anxiety and Depression Scale scores, the association between the survival rate and Hospital Anxiety and Depression Scale scores, and the survival rate based on the number of anastomosed vessels. Postoperative infection was defined as swelling, erythema, pain, purulent discharge, or a positive bacterial culture result. Patients were followed for 1 month. The differences in anxiety and depression scores between the two treatment groups and the differences in anxiety and depression scores based on failure of revascularization or replantation were determined. The difference in the risk of revascularization or replantation failure based on the number of anastomosed arteries and veins was assessed. Except for statistically significant variables (injury type and procedure), we thought that the number of arteries, number of veins, Tamai level, treatment protocol, and surgeons would be important. A multivariable logistic regression analysis was used to perform an adjusted analysis of risk factors such as postoperative protocol, injury type, procedure, number of arteries, number of veins, Tamai level, and surgeon.

RESULTS

Postoperative infection did not appear to increase without prolonged use of antibiotic prophylaxis beyond 48 hours (1% [3 of 327] versus 2% [3 of 138]; OR 2.4 [95% confidence interval (CI) 0.5 to 12.0]; p = 0.37). Intervention with antithrombotic and antispasmodic therapy increased the Hospital Anxiety and Depression Scale scores for anxiety (11.2 ± 3.0 versus 6.7 ± 2.9, mean difference 4.5 [95% CI 4.0 to 5.2]; p < 0.01) and depression (7.9 ± 3.2 versus 5.2 ± 2.7, mean difference 2.7 [95% CI 2.1 to 3.4]; p < 0.01). In the analysis based on the failure of revascularization or replantation, the Hospital Anxiety and Depression Scale scores for anxiety (11.4 ± 4.4 versus 9.7 ± 3.5, mean difference 1.7 [95% CI 0.6 to 2.8]; p < 0.01) and depression (8.5 ± 4.6 versus 7.0 ± 3.1, mean difference 1.5 [95% CI 0.5 to 2.5]; p < 0.01) were higher in the failed revascularization or replantation group than in the successful revascularization or replantation group. There was no increase in the artery-related risk of failure (one versus two anastomosed arteries: 91% versus 89%, OR 1.3 [95% CI 0.6 to 2.6]; p = 0.53). For patients with anastomosed veins, a similar outcome was observed for the two vein-related risk of failure (two versus one anastomosed vein: 90% versus 89%, OR 1.0 [95% CI 0.2 to 3.8]; p = 0.95) and three vein-related risk of failure (three versus one vein anastomosed: 96% versus 89%, OR 0.4 [95% CI 0.1 to 2.4]; p = 0.29). Factors associated with failure of revascularization or replantation included the mechanism of injury (crush: OR 4.2 [95% CI 1.6 to 11.2]; p < 0.01, avulsion: OR 10.2 [95% CI 3.4 to 30.7]; p < 0.01). Revascularization had a lower risk of failure than replantation (OR 0.4 [95% CI 0.2 to 1.0]; p = 0.04). Treatment with a protocol of prolonged antibiotics, antithrombotics, and antispasmodics was not associated with a lower risk of failure (OR 1.2 [95% CI 0.6 to 2.3]; p = 0.63).

CONCLUSION

With proper wound debridement and patency of repaired vessels, prolonged use of antibiotic prophylaxis and regular antithrombotic and antispasmodic treatment may not be necessary for successful digit replantation. However, it may be associated with higher Hospital Anxiety and Depression Scale scores. Postoperative mental status is associated with digit survival. Well-repaired vessels, instead of the number of anastomosed vessels, could be critical to survival and decrease the influence of risk factors. Further research on consensus guidelines that compare postoperative treatment and the surgeon's level of expertise after digit replantation should be conducted at multiple institutions.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Prognostic Factors for Attempted Finger Replantation and Revascularisation after Traumatic Amputation: A 16-Year Retrospective Cohort Study

Background: The aim of this study was to evaluate the impact of variant factors on finger replantation and revascularisation after traumatic amputation, which also included duty shift and the level of main operator. Methods: To determine the prognostic factors for the survival rate of finger replantation and revascularisation after traumatic finger amputation, we retrospectively reviewed the cases of finger replantation conducted from January 2001 to December 2017. Data collected consisted of the basic information of the patients, trauma-related factors, details of the operation and treatment outcomes. Descriptive statistics and data analysis was performed to assess outcomes. Results: In total, 150 patients with 198 replanted digits were enrolled in this study. The median age of the participants was 42.5 years, and 132 (88%) patients were men. The overall successful replantation rate was 86.4%. Seventy-three (36.9%) digits had Yamano type 1 injury; 110 (55.6%), Yamano type 2 injury and 15 (7.6%), Yamano type 3 injury. In total, 73 (36.9%) digits were completely amputated and 125 (63.1%) were not. Half of the replantation procedures (101, 51.0%) were performed during night shift (16:00-00:00), 69 (34.8%) during day shift (08:00-16:00) and 28 (14.1%) during graveyard shift (00:00-08:00). Multivariate logistic regression demonstrated that the trauma mechanism and type of amputation (complete vs. incomplete) significantly affect the survival rate of replantation. Conclusions: The trauma mechanism and type of amputation (complete vs. incomplete) significantly affect the survival rate of replantation. Other factors including duty shift and the level of operator did not reach statistically significance. Further studies must be conducted to validate the results of the current study. Level of Evidence: Level III (Prognostic).

The Role of Intravenous Heparin Following Digital Replantation: A Retrospective Cohort Study on 1,155 Digits

PURPOSE

The purpose of this study was to determine if the use of postoperative therapeutic dose intravenous heparin (POTDIVH) was indicated in digital replantation and revascularization by assessing digit survival and complications associated with heparin.

METHODS

All patients with amputation distal to the carpal tunnel treated at our center from 2004 to 2020 were included for chart review. Digit survival and complication rates were compared between patients who received POTDIVH (group A) and those who did not (group B). Logistic regression analysis and subgroup analysis were conducted.

RESULTS

A total of 795 patients (1,155 digits) were included in this study (248 patients/374 digits in group A and 547 patients/781 digits in group B). The overall revascularization and replantation success rate was 79.9% in the POTDIVH group and 92.8% in the non-POTDIVH group. In our retrospective regression and subgroup analyses, group A demonstrated increased odds of failure compared with group B and was associated with increased bleeding-related complications. Subgroup analyses stratified by the mechanism of injury and vein grafting also showed a significantly decreased survival in the POTDIVH group.

CONCLUSIONS

Our retrospective data seem to indicate that heparin in digit replantation and revascularization appears to have no benefit on digit survival across all subgroups, including crush and avulsion injuries, and is associated with a significantly increased rate of complications.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Single Digit Index Finger Amputation-To Replant or Not?

Background: Single index finger replantation is often listed as a contraindication due to its hindrance of hand function when replanted. Recent studies demonstrate comparable subjective and global functional outcomes for index flexor zone II finger replants versus revision amputations. We therefore sought to identify current opinions of plastic surgery trainees and staff treating single index finger zone II amputations including influential patient and injury characteristics. Methods: With the approval of the Canadian Society of Plastic Surgery, a 17-question survey was sent via email to all listed members on 3 separate occasions. Participation was voluntary and survey responses were compiled and analyzed using SPSS statistical software. Results: Survey response rate was 38.5%. When asked whether the surgeon would replant a single index digit, flexor zone II, sharp amputation, 55.3% of respondents chose "yes," while 44.7% responded "no." Staff (51.5%) were less likely to replant a single index digit amputation. Likelihood of replant dropped substantially in crush (12.4%) and avulsion (17.1%) injury. Smoking was the most likely patient characteristic to change a surgeon's decision (61.9%). Poor range of motion (77.5%) and patient satisfaction (72.5%) were the most frequently listed reasons not to replant. Conclusion: Among Canadian plastic surgeons, there exists disagreement in how single index flexor zone II amputations should be managed. In review of the literature, these notions and previous teaching around replants highlight many inherent surgeon biases with regard to the merit and value of single digit replantation.

Determinants of Success in Single- and Multi-Digit Replant

Purpose: Understanding the variables that influence success in digital replant surgery is essential to guide clinical decision-making and to counsel patients. The purpose of this study was to determine the replant success rate and identify predictors of success at our tertiary care centre. Methods: This was a single centre, retrospective cohort study of consecutive patients who underwent digital replantation from January 2000 to September 2018. Adult patients with flexor zone I to III amputations were included. Patient demographics, comorbidities, injury pattern, operative data, and post-operative care were reviewed. The primary outcome was survival of the replanted digit at discharge. Results: A total of 146 patients met inclusion criteria. Of these, 100 had single-digit replants and 46 underwent multi-digit replants for a total of 220 digits. The success rate was 71%. Predictors of success included sharp mechanism of injury (P < .01), incomplete amputation (P < .01), amputation proximal to zone I flexor level (P = .02), post-operative acetylsalicylic acid use (P < .01), absence of leech use (P = .05), and absence of operative re-exploration (P < .01). Daytime replants had similar outcome compared to nighttime replants despite having increased ischemia time (7.9 ± 3.9 hours vs 6.8 ± 2.6 hours, P = .02). However, daytime operative time (7.8 ± 3.7 hours) was significantly shorter than nighttime replant time (9.6 ± 5.9 hours, P = .01). Conclusion: Sharp amputation, intact venous drainage, proximal amputation, and acetylsalicylic acid use were associated with replant survival and are factors to consider when managing patients for digital replantation. Leech therapy and operative re-exploration were associated with poor outcome. Nighttime replants required significantly longer operative time than daytime replants despite similar survival outcome.

Influence on emergency digit replantation and outcome assessment after COVID-19 virus nucleic acid testing normalization

Objective

The study aims to compare the implementation and prognosis of emergency digit replantation surgery before and after normalized corona virus disease 2019 (COVID-19) nucleic acid testing for patients taking emergency operation and to explore the influence of normalized COVID-19 nucleic acid testing on replantation surgery.

Method

Normalized COVID-19 nucleic acid testing for patients taking emergency operation has been carried out since 1 August 2021 at our hospital, which means each patient who needs emergency surgical treatment has to obtain either positive or negative results of COVID-19 nucleic acid before entering the operating room. This research reviewed and compared the prognosis of the injured extremity that had emergency severed digit replantation between June and September 2021, at the Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, and analyzed the impact of normalized COVID-19 nucleic acid testing on the outcome of the replanted fingers of different severity using disability of arm-shoulder-hand (DASH) and hand injury severity scoring (HISS) scoring systems.

Results

A total of 54 cases with 74 severed replanted phalanges were included replanted by the research group between 1 August and 30 September 2021, without any COVID-19 suspected/confirmed case detected. Compared with previous period (1 June to 31 July, 2021), although the interval between emergency visits and emergency replantation did increase significantly after normalized COVID-19 nucleic acid testing [(3.83 ± 0.94) to (1.77 ± 0.67) h, P < 0.05], we observed no significant difference in the improvement rate of the DASH scoring of the disabled upper extremity 3-month postoperatively (P = 0.538) nor in the complication rate (P = 0.344). Moreover, there was no significant difference in the improvement rate of the DASH scoring of the disabled upper extremity 3-month postoperatively in patients with different traumatic severities before and after normalized COVID-19 nucleic acid testing (moderate P = 0.269, severe P = 0.055, major P = 0.149).

Conclusion

Despite the preoperative delay, the policy of COVID-19 nucleic acid testing normalization does not have explicit influence on the short-term outcomes of emergency digit replantation surgery. With this evidence, microsurgeons could pay attention to the patients' anxiety and spend more effort in comforting them during the prolonged preoperative wait. These insights may have implications for other emergency department resource management whenever a social crisis occurs.

Association Between Daytime vs Overnight Digit Replantation and Surgical Outcomes

Importance

Recent evidence suggests that select delayed replantation may not adversely affect digit survival; however, whether surgical timing (overnight or daytime) is associated with digit replantation outcomes is unknown.

Objective

To assess whether digit survival, complication rate, and duration of surgery are associated with time of replantation.

Design, Setting, and Participants

This retrospective case series study included all replantations performed at a single tertiary referral academic center between January 1, 2000, and August 1, 2021. Data were analyzed between October 2, 2021, and January 1, 2022. Four daytime surgery intervals were selected based on literature review. Daytime replantations started within the intervals whereas overnight replantations began outside the intervals. For each case, the procedure difficulty score and the attending surgeon expertise score were calculated. Logistic and linear regressions adjusting for confounders including procedure difficulty score and expertise score were used to assess surgical timing and outcomes. Participants were adults (aged ≥18 years) undergoing digit replantations between January 2000 and August 2021 with at least 1-month follow-up. Replantation was defined as the reattachment of a completely amputated digit that necessitated anastomosis of both artery and vein.

Exposures

Daytime or overnight digit replantation.

Main Outcomes and Measures

Viable replanted digit at 1-month follow-up, number of complications, and duration of surgery.

Results

A total of 98 patients (mean [SD] age, 39.5 [15.3] years; 136 [93%] men) and 147 digits met inclusion criteria. Overall success rate was 55%. Between 4 pm and 7 am, overnight replantations were associated with 0.4 fewer complications (β, -0.4; 95% CI, -0.8 to -0.1) and 90.7 minutes shorter operative time (β, -90.7; 95% CI, -173.6 to -7.7). A 1-point increase in surgeon expertise score was associated with 1.7 times increased odds of replantation success for all intervals (adjusted odds ratio, 1.7; 95% CI, 1.2 to 2.4; P = .002). There were no differences in digit survival by surgical time.

Conclusions and Relevance

In this case series study of digit replantations, time of operation was not associated with replantation success. Overnight replantation was associated with fewer complications and shorter duration of surgery compared with daytime surgery. Results of this study suggest that overnight replantations may be performed with outcomes comparable to daytime replantations at a tertiary care academic center.

Factors associated with early and late digital revascularization and replantation failure: a retrospective cohort study

Factors associated with failure of digital revascularization and replantation procedures have been well characterized, but studies have not investigated failures occurring beyond the early postoperative period. A single-centre retrospective chart review included 284 patients (434 digits) who underwent digital revascularization or replantation. Patient-, injury- and surgery-related characteristics were compared among successful procedures, digits that failed while in hospital (early failure), and initially viable digits that failed after hospital discharge (late failure). Overall, 202 patients had successful procedures (71%). There were 51 early failures (18%) and 31 late failures (11%). Crush injuries and vein grafting were associated with early failure only. Complete amputations and leeching were strongly associated with both early and late failure. This study revealed that a substantial proportion of initially viable digits fail after discharge from hospital. Patients with signs of venous congestion may benefit from longer observation periods in hospital to avoid late failure.Level of evidence: IV.

Systematic Review of Replant Salvage and Cost Utility Analysis of Inpatient Monitoring After Digit Replantation

PURPOSE

Digit replantation is a high-stakes procedure that has been shown to be cost-effective, especially for multiple-digit replantation. However, it is associated with prolonged lengths of stay (LOS) for monitoring and attempts at salvage. The cost-effectiveness of prolonged inpatient stays presumes that this is necessary and inherent to the replantation. We hypothesized that prolonged monitoring of replanted digits, in the hope of possible salvage after primary failure, is cost-ineffective due to the low rates of vascular compromise and salvage after replantation.

METHODS

Using previously published data comparing quality adjusted life years lost after traumatic digit amputation versus digit replantation, we devised a cost utility model to evaluate the incremental cost-effectiveness ratio of inpatient monitoring. To determine rates of vascular compromise and salvage after digit replantation, we performed a systematic review of the literature through MEDLINE and SCOPUS database searches to identify relevant articles on digital replantation since 1990. Cost-effectiveness was stratified based on the number of digits replanted.

RESULTS

Fewer than 9% of replanted digits both experience vascular compromise and are successfully salvaged. Adjusting for this, inpatient monitoring for single-digit and thumb replantation becomes cost-ineffective after 1 day of admission and monitoring for multiple-digit replantation becomes cost-ineffective after 2 days of admission.

CONCLUSIONS

In the United States, prolonged admissions for inpatient monitoring quickly become cost-ineffective, especially with relatively low rates of salvage. Surgeons should avoid extended hospitalizations for replant monitoring and should pursue enhanced recovery protocols for replantation, especially considering burgeoning health care costs in the United States.

TYPE OF STUDY/LEVEL OF EVIDENCE

Economic/Decision Analysis III.

Survival Statistics of Digital Replantation in the UK

Background

Digital replantation is associated with a substantial risk of failure. There is considerable variation in survival rates globally, and the current data are limited by poor statistical methods and bias of selection, which limits its translation to Europe and the USA. We aimed to establish a more representative survival rate of digit replantation for western populations and evaluate espoused prognostic variables using robust statistical methodology.

Materials and Methods

Retrospective data were collected from 58 consecutive patients who underwent digital replantation following traumatic amputation in three tertiary care hand centres in the UK over seven years. The unit of analysis was the digit. Generalized linear modelling was used to estimate the odds ratio (OR) of digit survival.

Results

Forty-six of 68 replanted digits survived (68%). The typical replant candidate was a 40-year-old male manual worker. Digit survival was more likely with guillotine injuries (adjusted OR 25.5 [95% CI 5.60, 115]) and when intraoperative skeletal shortening was performed (adjusted OR 15.3 [95% CI 2.62, 89.5]). The age of the patient, seniority of the operating surgeon, and use of vein grafts was not associated with digit survival.

Conclusion

We provide robust data to show that guillotine amputations have more favourable survival rates, which can be further improved by skeletal shortening at the time of replantation. We suggest that research networks worldwide set up digit amputation registries to capture individual patient data on this uncommon injury.

The Roles of Injury Type, Injury Level and Amputation Type in the Need for Revision Surgery after Replantation: Retrospective Clinical Outcome with 296 Finger Replantation

BACKGROUND

With the development of microsurgical techniques, the replantation survival rate has increased, but in some cases, revision surgery is required. Although there are many studies on replantation survival rate, studies on revision surgery are limited. In this study, we evaluated replantation patients requiring revision surgery in terms of amputation level, injury type, and amputation type (single-multiple).

METHODS

This is a retrospective study.Two hundred fifty-six patients (296 fingers) who were operated on for total finger amputation in our hospital between 2013 and 2018 were included in the study. In the postoperative period, revision surgery was required for 24 fingers due to vascular insufficiency. Patients were evaluated in terms of amputation level, injury type, and amputation type.

RESULTS

Two hundred sixty-four fingers were saved after primary surgery. Eight fingers failed before they could undergo revision surgery. Revision surgery was performed for 24 fingers. After revision surgery, 19 fingers were saved, and five fingers were failed. There was no significant effect of gender and age in terms of revision (p > 0.05).There was no statistically significant difference in injury level and injury type, but there was a statistically significant difference in terms of amputation type (p < 0.05).

CONCLUSION

Despite advanced microsurgery and experience, vascular insufficiency can be observed after replantation. Surgical re-exploration is necessary for salvage.

Comparative assessment of fingertip replantation in paediatric and adult patients within a single institution

The purpose of this retrospective study was to compare the outcomes of paediatric and adult fingertip replantation within a single institution. Our retrospective study found no significant difference in the survival rate between the paediatric (10/12) and adult (22/26) groups. At 6 months follow-up, there was no significant difference in sensory recovery between both groups, as measured with Semmes-Weinstein testing, but a significant difference in mean static two-point discrimination testing values between the paediatric (4.0 mm) and adult (6.2 mm) groups. Moreover, the mean time for regaining sensation was faster in paediatric patients (1.3 months) as compared with adult patients (4.1 months). Five children and four adults received erythrocyte transfusion. Paediatric fingertip replantation has similar survival rates, faster and better sensory nerve recovery as compared with adults despite a higher erythrocyte transfusion rate. Although technically demanding, paediatric fingertip replantation is recommended, whenever possible, because of the good outcomes achievable.Level of evidence: IV.

Delayed Digit Replantation: What is the Evidence?

A persistent challenge that has limited access and delivery of digit replantation surgery is timing, as ischemia time has traditionally been considered an important determinant of success. However, reports that the viability of amputated digits decreases after 6 hours of warm ischemia and 12 hours of cold ischemia are largely anecdotal. This review evaluates the quality and generalizability of available evidence regarding ischemia times after digit amputation and reported outcomes of "delayed" replantation. We identify substantial limitations in the literature supporting ischemia time cutoffs and recent evidence supporting the feasibility of delayed digit replantation. The current treatment approach for amputation injuries often necessitates transfers or overnight emergency procedures that increase costs and limit availability of digit replantation nationwide. Evidence-based changes to digit replantation protocols could lead to broader availability of this service, as well as improved care quality.

Variation in Surgeon Proficiency Scores and Association With Digit Replantation Outcomes

IMPORTANCE

Risk-adjusted variation in surgeon outcomes has been traditionally explained by surgeon volume and hospital infrastructure, yet it is unclear how a surgeon's operative proficiency directly contributes to their patients' outcomes.

OBJECTIVE

To assess the variation of surgeons' operative proficiency and investigate its association with surgical outcomes.

DESIGN, SETTING, AND PARTICIPANTS

This case series was a retrospective analysis of all digit replantations and revascularizations at a single US university medical center between January 2000 and August 2020. Surgeons were assigned a proficiency score based on the expected procedure difficulty and outcomes from a sample of their cases. Surgeon proficiency scores were then used to determine associations with outcomes from subsequent cases. The expected difficulty of each case was calculated using a novel scoring system that applied pooled relative risks from a meta-analysis of risk factors for replantation and revascularization failure.

EXPOSURES

Digit replantation and revascularization.

MAIN OUTCOMES AND MEASURES

Digit survival at 1-month follow up (case success) and number of complications.

RESULTS

A total of 145 patients and 226 digits were treated by 11 surgeons with training in hand or microsurgery (mean [SD] age, 41.9 [15.2] years; 204 [90%] men); there were 116 replantations and 110 revascularizations. Surgeon proficiency scores ranged from 1.3 to 5.7, with a mean (SD) of 3.4 (1.4). Case success rates among surgeons varied from 20.0% to 90.5%, with a mean (SD) of 64.9%. Higher proficiency scores were associated with fewer case failures: each point increase was associated with 40% decreased odds of failure (odds ratio, 0.60; 95% CI, 0.38-0.94). Every 3-point increase in proficiency score was associated with 1 less complication (effect estimate, -0.29; 95% CI, -0.56 to 0.02). Surgeon proficiency score had a greater association with case failure than surgeon volume (16.7% vs 12.0%). The final model's association with case failure had an area under the receiver operating characteristics curve of 0.93.

CONCLUSIONS AND RELEVANCE

Operative proficiency varied widely among practicing surgeons and accounted for 17% of estimative ability for success of digit replantation and revascularization. Greater surgeon proficiency was associated with better outcomes, indicating that the value of surgical care may be optimized by improving surgeon proficiency.

A 17-Year Experience in Hand and Digit Replantation at an Academic Center

BACKGROUND RESULTS

Results of replantation surgery of replantation surgery following upper extremity traumatic amputation are extensively described in the literature, with success rates varying from 57 to 100 percent. The purpose of this study was to evaluate replantation success rate at a Level I trauma center over a 17-year period and to assess definable factors contributing to these results.

METHODS

A retrospective review of all digit and hand replantations at a Level I trauma center was performed using CPT codes from 2001 through 2018. Descriptive analyses, Mann-Whitney test, Kruskal-Wallis test, and logistic regressions were used. Significance was defined as p ≤ 0.05.

RESULTS

Analysis consisted of 76 patients with 101 amputated parts (93 digits and eight hands). Fifty-six single digit amputations (30 percent success rate), 37 multidigit injuries (22 percent digit success rate), and eight hand amputations (50 percent success rate) were attempted. The overall success rate was 25 of 76 patients (33 percent) and 29 of 101 parts (29 percent). The most common mechanism of injury was laceration (n = 56), followed by crush (n = 30), and avulsion (n = 11), with repair of laceration-type injuries having the greatest success rate (36 percent).

CONCLUSIONS

The authors report a lower success rate of hand and digit replantation than previously described in the literature. Whole hand and thumb replantations resulted in the highest survival rate in our series. Laceration mechanism showed a higher success rate than crush or avulsion-type injuries. The authors' modest results highlight the importance of effective internal auditing of low-volume replantation centers such as their own. Quality improvement measures are proposed for higher future success in replantation surgery at the authors' institution.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Unique Techniques or Approaches in Microvascular and Microlymphatic Surgery

Several methods can be used for identifying tissues for transfer in donor-site-depleted patients. A fillet flap can be temporarily stored in other parts of the body and transferred back to the site of tissue defect, including covering the amputated stump of the lower extremity. Human arm transplant is rare and has some unique concerns for the surgery and postsurgical treatment. Cosmetics of the narrow neck of transferred second toes can be improved with insertion of a flap. Lymphedema of the breast after cancer treatment can be diagnosed with several currently available imaging techniques and treated surgically with lymphaticovenous anastomosis.

Clinical outcomes of salvage revision surgery following finger replantation with vascular insufficiency: A retrospective study

OBJECTIVE

The aim of this study was to analyze the outcomes of revision surgery following replantation of single digital amputations.

METHODS

In this study, first, a total of 403 patients (339 male, 64 female; mean age=28 years; age range=1-76) in whom a single finger replantation was performed were retrospectively reviewed, and then 60 patients with arterial or venous insufficiency in whom revision surgery was performed were reanalyzed. The second finger was observed to be the most injured one (32.8%). Injury type was classified as clean cut (25.3%), local crush (38.7), extensive crush (7.9%), and avulsion (28.1%). When taking the levels of injuries of the artery-only finger replantations into account, one finger (0.8%) was nail distal third, 70 fingers (56%) were nail distal third to lunula, 43 fingers (34.4%) were lunula to distal phalanx basis, 10 fingers (8%) were distal interphalangeal (DIP) joint, and one finger (0.8%) was middle phalanx. Operative revision was performed on 60 (14.9%) fingers. The need for operative revision was arterial insufficiency in 37 fingers (61.7%) and venous insufficiency in 23 fingers (38.3%). The average revision time was 43 (range=6-144) hours. While the average elapsed time for artery procedures was 35.3 (range=8-110) hours, the average elapsed time for vein procedures was 47.1 (range=6-144) hours. Finger survival rates were examined. Injury mechanism, amputation level, the number of artery/vein repairs and methods were examined in all patients and revision patients separately.

RESULTS

After the replantations, according to survival analysis, while 342 (84.9%) fingers were operated upon successfully, 61 (15.1%) fingers developed necrosis. In the patients with revision surgery, the survival rate was 78.3%. The need for revision was arterial insufficiency in 37 fingers (61.7%) and venous insufficiency in 23 fingers (38.3%). The revision rate was significantly lower than other injury types in clean-cut cases. In terms of levels of injury, no revisions were required from distal to lunula level, and the highest revision rate was observed at the proximal interphalangeal (PIP) joint level.

CONCLUSION

The results of the present study have shown that early re-exploration can provide a 78.3% success rate and can increase the survival rate from 67.6% to 84.2% following replantation of single digital amputations. Surgical re-exploration seems to be a reasonable salvage for replanted fingers with vascular insufficiency.

LEVEL OF EVIDENCE

Level IV, Therapeutic study.

A Global View of Digital Replantation and Revascularization

Survival rates of digital replantation vary in different regions and countries, and Asian surgeons see more challenging cases and have developed some unique methods. Replantation of multiple digits in one or both hands can follow a structure-by-structure method or a digit-by-digit method. For replanting all 10 digits, 3 or 4 teams should be organized. Flow-through flaps, often venous flaps, can be taken from the distal forearm or lower extremity to repair defects of soft tissues and arteries. A pedicled digital artery flap from the adjacent digit can also repair tissue defects and supply blood to the replanted digit.

Etiology and Survival of Secondary Revascularizations after Hand and Digit Replantations

Introduction  Hand and digit replantations can be complicated by vascular insufficiency necessitating revision of the original replantation. To date, few studies have evaluated outcomes in secondary revascularizations following replantation. Therefore, the objective of this study was to evaluate the incidence, etiology, and survival rates following secondary revascularization after hand and digit replantations. Materials and Methods  A literature search was performed on NCBI for studies documenting secondary revascularization procedures following hand and digit replant. Studies were evaluated for the etiology of vascular failure, frequency of secondary revascularization, and survival rates following intervention. Statistical analysis was conducted across the pooled dataset. Results  A total of 16 studies including 1,192 amputations were analyzed. We found that 16.9% (201/1,192) of replants were complicated by vascular compromise. The frequency of vascular compromise was not statistically different between arterial and venous etiologies. The survival rate following secondary revascularization was 55.6%, with no significant difference between the arterial and venous groups. Secondary arterial revascularization was often treated with arterial revision (nine of nine studies) and/or with vein grafting (two of nine studies). Secondary revascularization for venous insufficiency resulted in different survival rates for nonsurgical modalities (58%) versus vein revision (37.5%) versus vein grafting (100%). Conclusion  Survival rates following secondary revascularization are lower; however, they may be improved using vein grafts following venous insufficiency. These data can be used to better understand the etiology of replant failure and guide decision-making.

Practical Tips to Improve Efficiency and Success in Upper Limb Replantation

LEARNING OBJECTIVES

After reading this article, participant should be able to: 1. Describe the technique of replantation for very distal amputation of the digit and salvage procedures for venous drainage. 2. Perform single-digit replantation after viewing the videos. 3. Recognize appropriate cases for joint salvage techniques in periarticular amputation at each joint of the digit and wrist. 4. Outline the methods of flexor and extensor tendon reconstruction in an avulsed amputation of the digit or thumb. 5. Understand the order of digital replantation and transpositional replantation for a restoration of pinch or grip in multiple-digit amputation.

SUMMARY

This article provides practical tips and caveats for the latest replantation surgical techniques for digit, hand, and upper extremity amputation. Four videos, clinical photographs, and drawings highlight important points of operative technique and outcomes of replantation.

The Role of the Hand Surgeon in Microsurgery in Brazil

Objective  This study evaluates the conditions for microvascular procedures found by hand surgeons in Brazilian clinical practices.

Methodology  A prospective, observational, and analytical primary clinical research conducted during the 37 ^th Brazilian Congress of Hand Surgery, from March 30 ^th to April 1 ^st , 2017, in Belo Horizonte, in which physicians answered 12 closed, objective, multiple-choice questions regarding their geographic region, type of institution (public or private), microsurgical training, time of experience, technical conditions, the availability of a standby team for emergencies and compensation.

Results  The study analyzed 143 hand surgeons; among them, 65.7% participants were based at the Southeast region, 13.3% in the Northeast region, 11.9% in the South region, 6.3% in the Central-West region and 2.8% in the North region. Regarding the time of experience, 43.4% of the hand surgeons had less than 5 years, 16.8% had 5 to 10 years, 23.8% 10 to 20 years, and 23% had more than 20 years of practice in microvascular surgery. Seven percent of the surgeons had no training in microvascular surgery; for 63.6%, training occurred during medical residency, whereas 30.8% were trained in another institution, and 7.7% in another country. Among these surgeons, 76.9% worked at both private and public hospitals, 14.7% at private hospitals and 5.6% at public hospitals. Regarding compensation, 1.8% of the surgeons considered it adequate, and 98.2%, inadequate in public hospitals, whereas 5.0% considered it adequate, and 95.0%, inadequate in private hospitals.

Conclusion  This research shows that most surgeons were trained in microsurgery, had never performed reattachments, and considered that compensation is inadequate; moreover, standby teams were not available. There are few, unevenly distributed hand surgeons with microsurgical ability in emergency settings, and their compensation is low.

Revascularization and Replantation in the Hand: Presurgical Preparation and Patient Transfer

Replantation of a digit or hand is most successful when performed at a specialized, high-volume center. However, most patients with amputations initially present to local hospitals. Therefore, patients amenable to replantation frequently require expedited transfer to a tertiary center. To maximize success of digit replants, health care providers from both the referring and the referral hospital must be facile and expeditious at transferring the injured patient. The critical aspects of triage include assessment of the injury, patient communication, interfacility communication, preparation of the amputated part and patient, and a timely transfer.

Critical Ischemia Time, Perfusion, and Drainage Function of Vascularized Lymph Nodes

BACKGROUND

Vascularized lymph node transfer is a promising surgical treatment for lymphedema. This study investigated the effect of ischemia on the lymphatic drainage efficiency of vascularized lymph node flaps and the critical ischemia time of lymph nodes.

METHODS

Twenty-four lymph nodes containing groin flaps in 12 Sprague-Dawley rats were dissected. Clamping of the vascular pedicle was performed for 0, 1, 3, 5, 6, or 7 hours; then, each was allowed to reperfuse by means of the vascular pedicle for 1 hour. Perfusion and ischemic changes were assessed using indocyanine green lymphography; laser Doppler flowmetry; and histologic studies with associated lymphatic vessel endothelial hyaluronan receptor-1, CD68, 4',6-diamidino-2-phenylindole, terminal deoxynucleotidyl transferase-mediated dUTP nick end-labeling, and glutathione assay stains.

RESULTS

The mean latency period of the groin lymph node flaps was 247 ± 67, 83 ± 15, 72 ± 42, 30 ± 18, and 245 ± 85 seconds in the 0-, 1-, 3-, 5-, and 6-hour groups, respectively. Perfusion detected by laser Doppler was 85.2 ± 14.5, 87.2 ± 36.7, 129.8 ± 33.7, 140.4 ± 148.5, 156.1 ± 91.4, and 41.2 ± 34.8 perfusion units at ischemia times of 0, 1, 3, 5, 6, and 7 hours, respectively. Cell damage measured by glutathione was 46.8 ± 10.2, 67.7 ± 14.2, 62.8 ± 15.4, 126.6 ± 5.9, 259.0 ± 70.3, and 109.1 ± 27.5 at ischemia times of 0, 1, 3, 5, 6, and 7 hours, respectively. Histologically, as ischemia time increased, hemorrhage and congestion became more severe.

CONCLUSIONS

The critical ischemia time of vascularized lymph nodes is 5 hours in the rodent animal model, verified by indocyanine green lymphatic fluid uptake, laser Doppler perfusion, and histologic assessments. Interestingly, lymphatic drainage and perfusion of vascularized lymph nodes were improved with an increased ischemia time before the critical 5 hours was reached.

Transplantation of a Free Vascularized Joint Flap from the Second Toe for the Acute Reconstruction of Defects in the Thumb and other Fingers

BACKGROUND

This study aimed to evaluate a novel surgical method for the acute reconstruction of defects in the thumb and other fingers by transplanting a free vascularized joint flap from the second toe and to determine its clinical curative effects.

MATERIALS AND METHODS

A free vascularized joint flap from the second toe was transplanted to reconstruct a complete defect of the thumb and other fingers accompanied by the loss of the proximal finger in 10 patients. Of these patients, three had their thumbs reconstructed with a free vascularized joint flap from the second toe and with the proximal interphalangeal joint flap, one had a thumb reconstructed with a free vascularized joint flap from the second toe, and six had their finger defects reconstructed with the proximal interphalangeal joint flap. The toes of the metatarsophalangeal joint were amputated at the foot donor site. All patients underwent one-stage emergency surgery.

RESULTS

The composite tissue flaps, replanted thumbs, and fingers survived well in all 10 cases. Follow-up visits were conducted for 6-28 months, with an average of 9 months of follow-up. The transplanted bone joints healed over a period of 6-16 weeks. Bone nonunions and refractures did not occur, and the walking function of the foot donor site was not visibly affected.

CONCLUSION

A free vascularized joint flap from the second toe can be transplanted to repair defects in the thumb and other fingers. This technique can be applied to recover the appearance and function of fingers.

The success of salvage procedures for failing digital replants: A retrospective cohort study

BACKGROUND

The success of salvage procedures for failing digital replants (FR) is poorly documented. We sought to evaluate the success of salvage procedures for FR and factors contributing to successes and failures of replants.

METHODS

Adult patients who presented to our center between January 1, 2000 and December 31, 2015, suffered ≥1 digital amputation(s), and underwent digital replantation were included. Preoperative, perioperative, and postoperative details were recorded. Digits were monitored postoperatively via nursing and physician assessments. The presumed reason for failure, details, and outcomes of salvage attempts were recorded for FR. Length of hospital stay and complications were also recorded.

RESULTS

Fifty-two patients and 83 digits were included. Fifty-two digits (63%) were compromised (arterial ischemia in 15 digits; venous congestion in 37 digits) and 48 digits had salvage therapy. Twenty-one FR (44%) were salvaged via operative (1 of 2; 50%), nonoperative (19 of 43; 44%), and combined (1 of 3; 33%) therapies. FR patients were more likely than those with successful replants to receive a blood transfusion (52 vs. 23%; p = .009) with more transfused units (3.45 ± 3.30 vs. 0.86 ± 0.95; p = .001). Length of stay was prolonged for FR patients (9 [range: 2-22] vs. 7 [range: 3-19] days; p = .039). Ultimately, 59% (49 of 83) of replants were successful, where 25% (21 of 83) were successfully salvaged.

CONCLUSION

Nonoperative and operative salvage therapies improve the rate of replant survival. We suggest close postoperative monitoring of all replants and active salvage interventions for compromised replants in the postoperative period.

Immediate Versus Overnight-Delayed Digital Replantation: Comparative Retrospective Cohort Study of Survival Outcomes

PURPOSE

Ischemia time has been traditionally considered a critical factor in replantation survival rate. The objective of this study was to compare the survival rate between immediate and overnight-delayed digital replantation.

METHODS

We performed a retrospective cohort study of all digital replantations performed at our clinic between 2005 and 2016. The survival rate was compared between the immediate digital replantation group (immediate replantation group) and those that were replanted the morning after they were admitted to the hospital (overnight-delayed replantation group). The decision to delay the replant was made in cases admitted in the evening with less than 12 hours of previous ischemia time and without farm-related contamination.

RESULTS

Five hundred ninety-seven digital replantations (456 patients) were analyzed. One hundred eighty-five (31%) digital replantations were performed the following day (delayed replantation group) and 412 (69%) digital replantations were performed the same day that they were admitted to the hospital (immediate replantation group). The overall survival rate was 91.9% (549 of 597). In the immediate replantation group, the survival rate was 91.2% (376 of 412) and in the delayed replantation group, the survival rate was 93.4% (174 of 185). There were no statistically significant differences between the immediate and the delayed replantation groups with respect to age, zone of amputation, or presence of multiple amputations.

CONCLUSIONS

Our study suggests that overnight delay is a safe approach for digital replantation when performed by experienced microsurgeons.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Patency Test of Vascular Anastomosis with Assistance of High-Speed Video Recording in Digit Replantation

BACKGROUND

Quality assessment of vascular anastomosis primarily depends on the experience of the treating surgeon. This highlights the need for an objective index. The main goal of our study was to establish a method of assessing the quality of vascular anastomosis in digit replantation.

METHODS

A total of 182 digits from 141 patients were included in this study. The patients underwent replantation of completely amputated digits between June 1, 2015, and February 1, 2017. Patency tests of arterial and venous anastomoses were conducted for each replantation and recorded on digital video at 1,000 frames per second. We divided the study into 2 phases. In phase I (103 digits from 80 patients), we investigated whether the refilling velocity ratio (RVR) was associated with replantation failure. In phase II (79 digits from 61 patients), we adopted the RVR as a guiding parameter during surgery and compared the replantation success rate with that of the historical control of phase I.

RESULTS

In phase I, ischemia time (>12 hours), arterial RVR (<0.4), and venous RVR sum (<1.0) were significantly associated with the rate of replantation failure in 82 cases with single arterial anastomosis. In phase II, we set the arterial RVR goal to 0.4 and venous RVR sum goal to 1.0. Under the guidance of the RVR test, the survival rate significantly increased compared with that of the historical control of phase I (96% versus 87%; p = 0.037).

CONCLUSIONS

The patency test, with assistance of high-speed video recording, is a useful tool that can improve the success rate of digit replantation.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Predictors of Digit Survival following Replantation: Quantitative Review and Meta-Analysis

Introduction Microsurgical replantation following digital amputation has variable success rates. Sociodemographic factors and surgery-related variables have been shown to influence survival rates; however, few studies have evaluated these data systematically across a combined dataset. Therefore, the objective of this study was to analyze the current literature to identify the predictors of replant survival. Materials and Methods A literature review was performed using the PubMed/Medline database focused on complete digit amputation/replantation studies. Studies were evaluated for patient and surgery-related variables and their respective effects on survival. Statistical analysis was conducted to identify predictors of survival and derive pooled estimates from the combined dataset. Results Thirty-two studies representing more than 6,000 digit amputation/replantation cases met inclusion/exclusion criteria. Statistical analysis revealed the number of venous anastomosis (0 vs. 1 vs. 2), the number of arterial anastomosis (0 vs. 1 vs. 2), and the mechanism of injury (sharp cut versus blunt cut versus avulsion versus crush) to influence replant survival ( p < 0.05). The authors failed to find a significant association between survival and the following variables: age, sex, zone of injury, digit number, tobacco use, ischemia time, method of preservation, and use of vein graft. Conclusion Patient- and surgery-related variables affect digit survival following replantation. The etiology of injury can help risk-stratify patients and assist in an informed decision making process, whereas surgery-related factors can guide surgeon practice to improve clinical outcomes following replantation.

Techniques and survival incidence for revascularization of degloved fingers

We report techniques and survival incidence of three subtotally and nine completely degloved fingers in seven patients. We performed end-to-end arterial repairs in seven fingers, vein graft repairs for arteries in two fingers, arteriovenous anastomoses in three fingers. End-to-end vein anastomosis was performed in all fingers. One finger requred re-exploration. Soft tissues in the eight degloved fingers survived completely, two failed completely, and two were partially necrotic. We conclude from our results that following revascularization, the skin from a completely degloved finger skin will survive in approximately two cases out of three.

LEVEL OF EVIDENCE

IV.

Risk Factors of Acute Hand Injuries in Manual Workers: A Case-control study

The purpose of this study was to identify the risk factors of hand injuries in manual workers. Total 1672 manual workers with acute hand injuries who visited our emergency department accompanied by their colleagues from 1 March 2014 to 1 March 2017 were included in this study. One accompanied colleague with identical work task was chosen randomly as control for each patient. The personal characteristics including gender, age, work experience, acute hand injury history, smoking and alcohol consumption were recorded and compared. Finally, we found the history of severe and multiple times of acute hand injuries, high and very high daily alcohol consumption, working experience from one to two years were risk factors for acute hand injuries in manual workers.

Survival Rate of Limb Replantation in Different Age Groups

Revascularization of damaged limbs/digits is technically feasible, but indications for surgical replantation remain controversial. The authors analyzed the survival rate of upper limb amputations and the associated factors in different age groups. They grouped 371 limb/digit amputees (average age, 44 years; range, 2-85 years) treated in their hospital during the past 10 years into three groups based on age (young, ≤ 15 years, n  = 12; adult, 16-64 years, n  = 302; elderly, ≥ 65 years, n  = 57) and analyzed their injury type (extent of injury and stump status), operation method, presence of medical complications (Charlson comorbidity index), and survival rate. There were 168 replantations, and the overall replantation survival rate was 93%. The Charlson comorbidity index of the replantation patients was 0 in 124 cases; 1 in 32; 2 in 9; and 3 in 3, but it did not show any significant difference in survival rate after replantation. Eight elderly patients (14%) did not opt for replantation. Younger patients tended to undergo replantation, but they had lower success rates due to their severe injury status. The results of this study show that the survival rate of replantation in elderly patients is equal to that in adults. Stump evaluation is important for survival, but the presence of medical complications is not associated with the overall survival rate.

Digital revascularization and replantation using the wide-awake hand surgery technique

The use of local anaesthesia and adrenaline for hand surgery is gaining popularity; however, where vascularity is impaired, wide-awake surgery is considered a contraindication. We present our case series of five digital devascularizations and eight amputations that underwent surgery using the 'wide-awake' anaesthetic technique. A temporary digital tourniquet (< 20 min) was used in three cases to identify structures quickly. The anastomoses were performed under local anaesthesia without a tourniquet. All cases had successful re-establishment of blood flow with good perfusion to the digital tips; no cases were re-explored because of vascular crisis. Four cases had minor superficial soft tissue necrosis that healed secondarily. We conclude that digital revascularization and replantation can be performed under local anaesthesia with use of adrenaline and without detriment to the traumatized digit provided careful patient selection and adequate operator experience are available.

LEVEL OF EVIDENCE

IV.

Microvascular replantation of head and neck amputated parts: A systematic review

BACKGROUND

As opposed to upper and lower extremity amputations representing a considerable volume of admissions, the prowess of microsurgeons is seldom solicited in complex cases of head and neck replantation. Our aim was to determine the rate of successful replantation of craniofacial parts in a systematic review of the literature.

METHODS

We performed a systematic review of English literature using PubMed/MEDLINE for every replantation of a head and neck parts. Articles selected for analysis required to describe microvascular surgical techniques to be considered a replantation. The measured endpoint for a successful replantation was survival at hospital discharge.

RESULTS

From 113 articles from the literature, reported cases of replanted craniofacial parts included 90 scalps, 56 ears, 34 lips, 26 noses, 1 eyebrow, and 1 midface. A significant majority of amputations were described as an avulsion mechanism (78.4%), as opposed to cutting/sharp (17.3%) or crush-type (1.9%). The overall success rate at hospital discharge was 72.1%, with a partial failure at 20.2% and a complete failure at 7.7%.

CONCLUSION

Urgent replantation of head and neck amputated parts allow patients to recover in a timely manner and to decrease the need for secondary reconstructive procedures. The significant rate of success is a strong argument in favor of promoting access to care for replantation of craniofacial parts.

[Strategies for complex injuries of the hand]

The quality of the reconstruction, follow-up treatment and care determine the treatment outcome of complex hand injuries. The initial estimation and therapy are decisive. Optimal results necessitate a structured approach with strategic planning, including thorough débridement, precise analysis of the resulting defect and loss of function and if possible unilateral reconstruction and well-founded planning of secondary interventions. Within the framework of the detailed patient clarification the perspectives, possibilities and alternatives must be realistically presented. Taking these fundamental strategic steps into consideration, the primary aims of reconstruction and preservation of function, rapid occupational and social reintegration and avoidance of delayed complications can best be realized. There is no standard approach for these extremely variable injuries. Decisive is that even in cases of apparently harmless injuries, the involvement of functional structures must be considered early in the initial stages.

The Biomechanical Impact of Digital Loss and Fusion Following Trauma: Setting the Patient up for Success

Surgeons managing mutilating hand injures are faced with difficult decisions between attempting to salvage remaining or injured digits or proceeding to amputation and fusion. Through application of a basic understanding of hand biomechanics, the surgeon may more accurately predict what motion and function can best be salvaged. This article provides an explanation of how amputation, fusion, and tendon loss can affect postoperative hand motion. The surgeon can use these concepts in planning the reconstruction or preparing the foundation for secondary reconstructive procedures to achieve the highest functional outcome for the patient.